Smoking and pain

There is a link between having chronic pain and smoking. Although no-one is really certain of the nature of this relationship, after working for a long time in pain management, I know many of the people I saw smoked tobacco. There have been a number of studies examining the nature of the relationship between smoking and chronic pain, with the prevalence of smoking amongst people with pain reaching around 42%. Some studies have found associations between smoking and mood disorders, personality disorders, and socio-environmental factors including more economic hardship.

People who smoke often say they do so to help deal with the stress of having pain, and there is some evidence that nicotine can have a short term analgesic effect (Ditre, Brandon, Zale & Meagher, 2011). One study by Patterson, Gritzner, Resnick, Dobscha, Turk and Morasco (2012) found that smokers who used cigarettes to cope with pain were more distressed, reported greater pain intensity, and greater fear of pain, while another study showed that people who smoked to deal with pain had poorer sleep, more fatigue, and less confidence to deal with their pain (Burris, Perez, Evans & Carlson, 2013).

The rates of tobacco smoking in the general population have been decreasing, at least in New Zealand. Yet amongst people with chronic pain, there are still many people who find it difficult to quit. Zale and colleagues surveyed 132 people from the local community and found that nearly 60% of them had pain in the last month. Those who had experienced pain said they had less confidence to stay off the tobacco, and had more trouble quitting during their last attempt to quit. At the same time, people who were experiencing pain were more motivated to quit and were more likely to be in the “contemplation/preparation” phase of the decision to quit compared with people who had no pain.

What this means is that although pain management is our primary focus, we should not forget that overall health is what we’re aiming for. We know there is a relationship between having pain and smoking, and there are many different mechanisms thought to be responsible for this (Ditre, Brandon, Zale & Meagher, 2011). We also know the very clear negative health effects of smoking, and with the cost of tobacco rising in New Zealand (and elsewhere) in an effort to encourage people to quit, we also know the economic impact of smoking on people who very often don’t have the financial resources to afford it. You might be surprised, however, to know that one study showed reduced pain in those who had quit smoking over the course of their treatment for back pain (Behrend, Prasarn, Coyne, Horodyski, Wright & Rechtine, 2012).

What prevents us from actively promoting smoking cessation in our patients?

I was trained in smoking cessation, but I wasn’t able to use those skills because my then manager didn’t think that providing support for people to quit smoking was relevant to pain management. That’s one reason smoking cessation is not a focus. Unless systems including funding and time support clinicians to help people to quit, it’s not going to happen. I guess I was disappointed that the bigger picture of healthcare savings wasn’t shared by my manager.

But the desire to quit smoking is a delicate flower, it needs nurturing and support especially while in the early stages of thinking about or getting ready to quit. Handing a person on to another agency to deal with smoking provides a great opportunity for that person to fall through the gaps.

Other clinicians are aware they don’t have the skills to support someone to quit smoking. It can take time, it can take resources and it does take some skill to work alongside the person to quit what is a potent drug with a very rapid effect. But skills can be learned, and there is plenty of material available to help you as a clinician to develop these skills. And lots of support material you can give to the person. Here’s New Zealand’s Quitline,Smokefree NZ, the American Cancer Society Guide to Quitting Smoking, and the Australian Smokefree site.

Specific issues for people with chronic pain who want to quit smoking

People may say they use smoking to deal with the stress of having chronic pain. What better time to quit, then, than when you’re working with someone who can help you deal with stress more effectively?

People find that using opioids increases their tendency to crave tobacco. Again, it’s easier to quit when people are available to help you through the process.

The stress of all the treatment processes involved during treatment within an interdisciplinary pain management programme is cited as a reason for continuing to smoke – again, when things are changing all around, this is a great time to incorporate quitting.

For clinicians – learning how to help someone prepare to quit smoking, then remaining with them through the process is a privilege and a clear responsibility. Smoking is not a healthy way to deal with stress, it’s expensive, it increases pain and the risk of chronic pain, and it’s associated with poorer coping. There is plenty of information and resources out there to help you support someone through the process, so use it. From this study by Zale and colleagues, we know that the importance of quitting is high when people have pain, but their confidence is very low – we can help build confidence, so let’s just do it.